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Letters to the Editor |
Department of Diagnostic Imaging, University Hospital Istituto Policlinico San Donato, 20097 San Donato Milanese, Milan, Italy e-mail: f.sardanelli@grupposandonato.it
Franca Podo, PhD
Department of Cell Biology and Neurosciences, Istituto Superiore di Sanità, Rome, Italy
Editor:
Because of the combined increase in incidence and survival rate, we face more and more women with a personal history of breast cancer. They are excluded from screening programs. In fact, they should undergo a follow-up program more intensive than the biannual mammographic examination commonly offered to the general 50–70-year-old female population. The aim is early diagnosis of both local cancer recurrence, which is more frequent during the first 5 years after primary treatment, and ipsilateral or contralateral second breast cancer, for which these women have an increased risk.
Intensive follow-up is performed during the first 5 years after diagnosis of cancer, but no consensus seems to exist on the duration and frequency of follow-up, nor on the schedule of examinations (1). What happens 5 years after the first event? Theoretically, these women should be scheduled for annual mammography, but this is not always the case for many reasons. They frequently forget the breast cancer event and underestimate the need for periodic controls, partly due to concurring important events (negative or positive) in their lives. Andersen et al (2) reported that 30% of female survivors of breast cancer living in rural communities had not undergone mammography in the preceding year. The dramatic consequence is delayed detection and a worsened prognosis (3). Our opinion is that the exclusion of women with a personal breast cancer history from screening programs should be reevaluated. Including them could remind them of the need for periodic controls, offering immediately a scheduled mammographic examination.
Moreover, for women with familial or genetic (BRCA1 or BRCA2) breast cancer predisposition, this exclusion should be avoided. Intensive screening programs, including physical examination, mammography, ultrasonography (US), and contrast material–enhanced magnetic resonance (MR) imaging, were demonstrated to allow early visualization of breast cancer in these women, with MR imaging showing the highest sensitivity (4). A screening program in 235 women with hereditary high risk demonstrated a breast cancer incidence of 10.2% (nine of 88) in women with a personal history of breast cancer and 6.1% (nine of 147) in those without, with 40% of all the cancers being detected with only MR imaging (5). Thus, women with genetic familial high risk and personal history of breast cancer should be included in surveillance programs for women with hereditary predisposition to the disease. An annual multimodality imaging protocol is the most intensive surveillance we can offer, since these women have the highest probability of breast cancer because of the already phenotypically expressed hereditary risk.
In conclusion, the increasing survival rate and the availability of intensive screening programs for women with hereditary predisposition to the disease mean that women with a personal history of breast cancer should be included in surveillance programs.
REFERENCES
Department of Diagnostic Radiology, Yale University School of Medicine, 333 Cedar Street, PO Box 208042, New Haven, CT 06520–8042. e-mail: liane.philpotts@yale.edu
Drs Sardanelli and Podo have raised an important and timely topic concerning the imaging follow-up of patients with a history of breast cancer. The issue of appropriateness of screening versus diagnostic mammography in such patients has been controversial for some time. There remains no agreed-upon standard of care in this setting. A wide range of practices currently exists in the United States. Some consider examinations in patients with a history of breast cancer as diagnostic examinations, some consider them screenings, while others differentiate patients who have undergone mastectomy from those who have undergone lumpectomy, and still others vary their practice according to the interval since the time of diagnosis (eg, 5 years).
The shortage of breast imagers is a serious problem to contend with. Diagnostic mammography is time-consuming and costly in comparison to screening mammography. Given that routine mammographic images (mediolateral oblique and craniocaudal views) are obtained in all patients, whether screening or diagnostic, and the search for signs of malignancy is, presumably, as vigilant in all patients, the reasoning behind the need for diagnostic mammography is tenuous. Scientific study has shown, in fact, that patients with a history of breast cancer actually have similar outcomes in screening programs to those without such a history (1). That is, the need for recalls for additional imaging from screening examinations is not significantly different in such patients from the normal population. Placing patients with a history of breast cancer in a screening pool frees up slots for other diagnostic patients, which helps to reduce wait times and backlogs. Given the current situation, this practice should probably be encouraged.
The issue raised by Drs Sardanelli and Podo is more complex in that screening policies differ in Europe from those in North America. A biannual screening schedule for women between the ages of 50 and 70 years is common in much of Europe. Some programs may only include single-view rather than two-view mammography. Many patients with a history of breast cancer are not included in this age range, and all should ideally undergo two-view annual, rather than biannual, imaging. Flexibility in inclusion criteria and frequency of examinations would be required. Thus, considerable changes would have to be addressed by European screening programs to allow inclusion of women with a history of breast cancer.
Probably the most important issue raised is that of multimodality screening. Studies have shown that MR imaging is effective in the detection of cancer in patients at increased risk for breast cancer (2–5). MR imaging was found to have a higher cancer detection rate than mammography in certain groups of patients, particularly young patients and those with dense parenchyma. US has also been shown to depict cancers not detected at mammography (6,7). However, showing that MR imaging, US, or any other imaging modality can demonstrate cancer does not ensure a reduction in mortality, which is the ultimate goal of any screening test. Great caution is required in offering these additional imaging techniques and adopting them into practice. The potential for false-positive findings leading to additional imaging and biopsy is substantial and the cost considerable. Patients must be aware of the benefits and disadvantages of these imaging modalities. This involves considerable counseling not practical in many screening programs. Thus, the suggestion by Drs Sardanelli and Podo of placement of such patients who might benefit from multimodality imaging in screening programs is not proved at this time.
Ultimately, we want the best outcome for our patients. Mammography (whether screening or diagnostic) should be made available to all, yet other tests should also be offered and reimbursed if used appropriately. New imaging modalities have become widely available, and the efficacy in finding cancer seems too valuable to be ignored. We will have to find ways to deal with these issues. Patients are aware of these modalities, and many are quick to embrace and demand them. Ongoing studies will continue to help determine what tests are appropriate for which patients. In North America, Europe, and worldwide, we must remain open minded and flexible so that women receive timely and appropriate diagnoses in a cost-effective manner that does not overburden our health delivery systems. This is a challenging task.
REFERENCES
This article has been cited by other articles:
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  F. Sardanelli, F. Podo, G. D'Agnolo, A. Verdecchia, M. Santaquilani, R. Musumeci, G. Trecate, S. Manoukian, S. Morassut, C. de Giacomi, et al. Multicenter Comparative Multimodality Surveillance of Women at Genetic-Familial High Risk for Breast Cancer (HIBCRIT Study): Interim Results Radiology, March 1, 2007; 242(3): 698 - 715. [Abstract] [Full Text] [PDF]
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